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This is a case report of a neonatal cholinesterase inhibitor poisoning after non-accidental ingestion of a carbamate containing pesticide by the mother prior to delivery. The mother presented with symptoms of cholinesterase inhibitor poisoning at 40 weeks of gestation. A fetal bradycardia was present. The mother improved after administration of intravenous atropine. Spontaneous labour ensued and a term female infant weighing 3200 g was delivered. The infant had signs of cholinergic stimulation and decreased levels of serum cholinesterase. The neonate presented with a marked tachycardia. The heart rate normalized after administration of atropine. Therefore, we concluded that the tachycardia was due to the cholinesterase inhibitor substance, causing catecholamine release by stimulation of nicotinic receptors. Another potential contributing factor to the tachycardia, although unlikely in our patient, was the atropine administered to the mother prior to delivery. Mother and infant recovered well. We conclude that infants can present with tachycardia associated with cholinesterase inhibitor toxicity. Despite the side-effects intravenous atropine should not be withheld in the treatment of mother and infant.

BACKGROUND The high regional incidence of hepatocellular carcinoma (HCC) in South Africa also may be present in children of the region, although the link to hepatitis B (HBV) appears less clear. The objective of this study was to assess the incidence and probable causes of HCC in South African children. METHODS Data were obtained from seven participating pediatric oncology units and from the tumor registry to review hepatic tumors in children in South Africa. RESULTS One hundred ninety-four children (ages 0–14 years) presented with malignant primary hepatic tumors (1988–2003). One hundred twelve tumors (57%) were hepatoblastoma (HB), 68 tumors (35%) were hepatocellular carcinoma (HCC) (including 9 patients with the fibrolamellar variant, 6 of which occurred in black children), 10 tumors (5%) were sarcoma of the liver, and 4 tumors were lymphoma. The ratio of HB to HCC (1.67) was markedly lower compared with other reports, suggesting a greater prevalence of HCC. Correlation with population statistics indicated an incidence of 1.066 malignant liver tumors per year per 106 children age < 14 years (HB, 0.61 per 106 children; HCC, 0.39 per 106). Two-thirds of patients with HCC were positive for HBV surface antigen (HBsAg), and HCC occurred mostly in black African patients (93%). The mean age of onset was 1.47 years for HB and 10.48 years for HCC. A preponderance of males (3.5:1.0) was noted in the HBsAg-positive group that was not reflected elsewhere. Serum α-fetoprotein (AFP) levels were raised both in patients with HB (100%; most AFP levels were very high) and in patients with HCC (69%), although 15% of patients with HCC had low or normal AFP levels. CONCLUSIONS It appeared from the current results that HCC is more prevalent among children in South Africa compared with the children in more developed countries, although their rates were lower that the rates noted in adults. A collaborative approach will be required to improve their diagnosis and management. Cancer 2004. © 2004 American Cancer Society.

The under-five-mortality rate (U5MR), as a robust child health indicator, is 109 per 1000 live births in Africa, of which infectious diseases comprise the bulk of paediatric disease.1 The U5MR exceeds 100/1000 live births in 24 countries, of which 23 are in sub-Saharan Africa.2 The major causes of death include pneumonia (18%), malaria (17%), diarrhoea (12%) and the human immunodeficiency virus (3%).3 Fortunately there has been progress, with a reduction in the U5MR, since 1990 in six African countries, namely Ethiopia, Rwanda, Liberia, Malawi, Niger and Madagascar.2 To improve the survival of children in sub-Saharan Africa it is important to implement interventions that will reduce the U5MR. An important intervention in the management of common infections is the implementation of and strict adherence to standard treatment guidelines. This has been proven to reduce both morbidity and mortality rates for pneumonia in adults.4,5 Similar adherence has also been proven to reduce in-hospitality mortality for children suffering from malaria.6 The additional benefit of adherence to standard treatment guidelines is that it is a cost-saving tool for hospitals.7 This issue reports on the adherence to standard treatment guidelines introduced by Medecin Sans Frontieres (MSF) in two sub-Saharan African countries, with different findings. The two countries are Sierre Leone, with an U5MR of 185/1000 live births and Somalia with an U5MR of 180/1000 live births, both members of the 24 countries exceeding the U5MR of 100/1000 live births. De Bruycker et al. report on non-adherence to standard treatment guidelines for lower respiratory tract infections (LRTI) and malaria for hospitalised children in rural Sierra Leone.8 Non-adherence was more common for LRTI (cumulative 86%) than for malaria (12%). Non-adherence was, furthermore, significantly associated with unfavourable hospital outcome for both LRTI and malaria. Of note is the difference in non-adherence to guidelines for the two diseases. This is probably linked to the complexity of the guidelines for the disease, where the guidelines for malaria are standardised, with fewer drug options, than LRTI, which has more complex drug options. Ngoy et al., on the other hand, report a low adverse outcome of only 6% for their paediatric in-patient study population in Somalia, a conflict-torn country.9 The possible reasons for the low adverse outcome include adherence to guidelines standardised by MSF, as well as provision of all health services free of charge by aid organisations. Other reasons include the training of staff and the provision of a telemedicine service for continuing medical support. This achievement is of great importance in the face of very limited numbers of health care staff for the case load. Both studies add important findings to the literature on strategies to address Millennium Development Goal 4 in sub-Saharan Africa. Key findings include the improved outcome of hospitalised children if there is good adherence to guidelines and training of health care staff in the implementation of these guidelines. It is also important to regularly monitor the adherence to standard treatment guidelines in hospitals to ensure rational drug use and that adherence is maintained. It is encouraging to note this can be achieved even in conflict-stricken countries.

AIM: To examine false-positive HIV DNA polymerase chain reaction (PCR) test results in children, and the potential implications for the paediatric HIV epidemic in sub-Saharan Africa. METHODS: A review was done of records over a 6-year period of children less than 18 months old at an HIV treatment site in South Africa, to evaluate those with an initial 'false'-positive HIV DNA PCR result, but later proven to be HIV-uninfected with HIV DNA PCR and/or quantitative HIV RNA PCR tests. We calculated the influence of changing HIV transmission rates on predictive values (PV) of HIV DNA PCR tests in a hypothetical population of all HIV-exposed infants over a 1-year period. (Positive PV: proportion of individuals with a positive test with disease; negative PV: proportion of individuals with negative test and no disease). RESULTS: Of 718 children, 40 with an initial positive HIV DNA PCR test were subsequently proven to be HIV-uninfected, resulting in a positive PV of 94.4%. Most (75%) uninfected children had PMTCT interventions and were asymptomatic or mildly symptomatic (77.5%). Calculations using a test specificity of 99.4%, as reported previously, show a decrease in positive PV using a single-test strategy from 98.6% at 30% HIV transmission rate, to 94.8% at 10% transmission, to 62.5% at 1% transmission. Reduction in test specificity further decreases positive PV at low transmission rates. CONCLUSION: Decreasing mother-to-child HIV transmission rates reduce the positive predictive value of a single HIV DNA PCR test result, necessitating adaptations to diagnostic algorithms to avoid misdiagnosis and inappropriate treatment, especially with early initiation of antiretroviral therapy in asymptomatic infants.

The expression and co-expression profiles of functionally important monocyte surface markers were compared between control and HIV+ individuals using combined physical gating and dim CD4 expression to delineate the monocytes. The Fc gamma RII (CD32), the MHC class II antigen HLA-DR and the adhesion molecules CD11a (LFA-1 alpha), CD18 and CD54 (ICAM-1) showed an unimodal distribution. Of these markers, CD11a and HLA-DR were up-regulated in the HIV+ subjects compared with controls. The expression levels of the adhesion molecules correlated with each other in both patients and controls. The CD11b (CR3-alpha), CD14, Fc gamma RI, and Fc gamma RIII markers were bimodally distributed. Compared with controls, monocytes from seropositives contained fewer CD14bright+ cells, an equal proportion of Fc gamma RIbright+ cells, but twice as many Fc gamma RIII+ cells. The expression level of Fc gamma RI and CD11b within their brightly positive subset increased as CD4 T cells decreased. Both in patients and controls, co-expression of bright CD11b, CD14 and Fc gamma RI was shown, whereas the Fc gamma RIII+ cells were negative or dim positive for the former triad. We conclude that the expression of two Fc gamma R (I and III), of the adhesion molecules CD11a and CD11b and of HLA-DR showed particular alterations on monocytes from HIV+ subjects. The relationship of these phenotypic observations with altered cytokine profiles and altered monocyte function is discussed.

The aim of the study was to determine the incidence of tuberculosis in newly diagnosed HIV-infected children and to determine whether anti-tuberculosis prophylaxis is indicated. We prospectively investigated newly diagnosed HIV-infected children for tuberculosis during the period June 1995 untill September 1996. A chest X-ray and a Mantoux test were done in all children. The Mantoux test was correlated with a skin test for Candida. Gastric aspirates were obtained from all children and sent for M. tuberculosis culture. There were 75 children in the study group. The mean age was 13.8 months. According to the CDC classification for HIV-infection, 37% of children were in the B3 category. The common clinical problems were as follows: Bronchopneumonia-58%; candidiasis-36%, hepatosplenomegaly and lymphadenopathy-39%; and marasmus 18%. Tuberculosis was diagnosed in 22% of children. Seven children had positive cultures on gastric aspirates for M. tuberculosis and eight children had chest X-rays highly suggestive of pulmonary tuberculosis. Two children had unproven tuberculosis, but responded dramatically to anti-tuberculosis therapy. In conclusion, the indidence of tuberculosis in newly diagnosed HIV-infected children was unexpectedly high(22%). This can probably be explained by the high incidence of tuberculosis in South Africa. The recommendation is that newly diagnosed HIV-infected children in our setting receive anti-tuberculosis prophylaxis.

Background The prevention of mother-to-child transmission (PMTCT) program in South Africa is now successful in ensuring HIV-free survival for most HIV-exposed children, but gaps in PMTCT coverage remain. The study objective was to identify missed opportunities for prevention of mother-to-child transmission of HIV using the four PMTCT stages outlined in National Guidelines. Methods This descriptive study enrolled HIV-exposed children who were below the age of 7 years and therefore born during the South African PMTCT era. The study site was in Gauteng, South Africa and enrolment was from June 2009 to May 2010. The clinical history was obtained through a structured caregiver interview and review of medical records and included socio-demographic data, medical history, HIV interventions, infant feeding information and HIV results. The study group was divided into the “single dose nevirapine” (“sdNVP”) and “dual-therapy” (nevirapine & zidovudine) groups due to PMTCT program change in February 2008, with subsequent comparison between the groups regarding PMTCT steps during the preconception stage, antenatal care, labor and delivery and postpartum care. Results Two-hundred-and-one HIV-exposed children were enrolled: 137 (68%) children were HIV infected and 64 (32%) were HIV uninfected. All children were born between 2002 and 2009, with 78 (39%) in the “sdNVP” and 123 (61%) in the “dual-therapy” groups. The results demonstrate significant improvements in antenatal HIV testing and PMTCT enrolment, known maternal HIV diagnosis at delivery, mother-infant antiretroviral interventions, infant HIV-diagnosis and cotrimoxazole prophylaxis. Missed opportunities without improvement include pre-conceptual HIV-services and family planning, tuberculosis screening, HIV disclosure, psychosocial support and postnatal care. Not receiving consistent infant feeding messaging was the only PMTCT component that worsened over time. Conclusions Multiple missed opportunities for optimal PMTCT were identified, which collectively increase children’s risk of HIV acquisition. Although HIV-testing and antiretroviral interventions improved, all PMTCT components need to be optimized to reach the goal of total pediatric HIV elimination. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-1265) contains supplementary material, which is available to authorized users.

CD14 is a differentiation-stage-linked glycosyl-phophatidyl-inositol-linked glycoprotein on human peripheral blood monocytes and tissue macrophages, which functions as a receptor for lipopolysaccharide. Here, the effects of granulocyte macrophage colony-stimulating factor (GM-CSF1 a cytokine with proliferation- and differentiation-inducing properties on myeloid lineage cells, were studied on CD14 expression by peripheral blood cells. GM-CSF down-regulated the membrane expression of CD14 on monocytes while it up-regulated expression on neutrophils. GM-CSF also decreased the spontaneous release of CD14 in monocyte culture supernatants. Down-regulation of CD14 expression and release was accompanied by a decrease in the mRNA transcript for CD14, suggesting that it most likely reflects an effect on the transcriptional level. The functional significance of this phenomenon, and its potential relation to the terminal differentiation of monocytes, are discussed.